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The Echo Manual

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CHAPTER 12 PERICARDIAL DISEASES

interdependence (59). Chang et al. demonstrated that [ 18 F]FDG PET/CT can detect pericardial inflammation and predict the response to steroid therapy with a high accuracy in patients with constriction (60). Although this was a small study involving 16 patients, an increased stan- dardized uptake value of greater than 3 predicted a com- plete response to 3 months of steroid therapy (Fig. 12-38), while high-sensitivity C-reactive protein and erythrocyte sedimentation rate tests did not predict reversibility of constriction. Echocardiography has become the initial diagnostic pro- cedure of choice for various types of pericardial diseases as discussed in this chapter since its first application to detect pericardial effusion noninvasively more than 50 years ago. This method is capable of providing a compre- hensive assessment of pericardial effusion (its amount and hemodynamic significance), guiding the pericardio- centesis (locating the optimal site and monitoring), and helping to establish or suggest the diagnosis of constrictive pericarditis. In some patients, constrictive pericarditis is transient, usually occurring after acute pericarditis, cardiac surgery, or pericardiocentesis. The development and reso- lution of transient constrictive hemodynamics are readily assessed with serial 2D Doppler echocardiography studies. The detection of respiratory variation in the mitral flow and central venous flow velocities as well as ventricular septal motion may be an initial diagnostic clue to con- strictive pericarditis, even in patients in whom a pericar- dial abnormality is not suspected clinically. Frequently, pericardial effusion is secondary to an underlying systemic or another cardiac abnormality, and echocardiography can Clinical Impact of Echocardiography on Pericardial Diseases

and visceral pericardium via en face views, demonstrat- ing strands, adhesions, and the extent of pericardial thickening in constrictive or effusive-constrictive peri- carditis (54,55). The extent of pericardial effusion can be accurately gauged, which may help to identify the best site for pericardiocentesis (56). 3D echocardiography may have utility imaging pericardial masses, includ- ing tumors, cysts, and hematomas (57). The 3D dataset can be electronically cropped to more fully characterize these abnormalities. Because experience with 3D imag- ing in pericardial disease remains limited, it is prudent to confirm novel or unexpected findings with other imag- ing modalities before making important management decisions. CARDIAC CT, MRI, AND NUCLEAR IMAGING Multimodality cardiovascular imaging (CT, MR, and nuclear imaging) has an important diagnostic and thera- peutic role in pericardial disease (1). It permits compre- hensive delineation of cardiac morphology (Fig. 12-37) and is superior to echocardiography alone in the identi- fication of a thickened or calcified pericardium (1). For this indication, CT appears superior to MRI (58). Using contemporary CT or MRI scanners, normal pericardial thickness should not exceed 2 mm (1,58). Cardiac MRI can detect pericardial inflammation, which manifests as delayed gadolinium hyperenhancement (Fig. 12-34), and has specific utility in the management and follow- up of patients with inflammatory constrictive pericardi- tis (53). In patients with painful recurrent pericarditis, delayed enhancement on cardiac MRI can guide the dura- tion and type of anti-inflammatory medical treatment. Cardiac MRI can also provide functional information, including metrics of diastolic filling and ventricular

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FIGURE 12-37 Cardiac CT of the heart and the pericardium showing a mass (which turned out to be a scar tissue and hematoma) compressing the LV ( arrows ) in a patient with a previous pericardiectomy ( left ) and a calcified peri- cardium ( arrows ) and mass (*) in another patient with constrictive pericarditis ( right ).

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